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HKSEMS eNewsletter Issue 009
2019Apr

香港急症醫學會

Hong Kong Society

for Emergency Medicine & Surgery
The president of HKSEMS, Dr Ludwig Tsoi will talk about " Perceptual error and artificial intelligence". Please click here for further reading.  

HKSEMS has been collaborating with School of Chinese Medicine in HKBU since the year of 2001 to offer an EM module to its students. Please click here to read more.

The 11th Asian Conference on Emergency Mediicine (ACEM) will be held in Hong Kong from 17-19 December 2021! Please mark the dates on your calender !

Message from the President      Dr Ludwig Chun-Hing TSOI

Perceptual error and artificial intelligence
 
Introduction
In February 2019, the Hospital Authority announced an initiative to introduce AI (“artificial intelligence”) to read chest x-ray films in the wake of several counts of “missed x-ray signs” as reported by the news recently (1). So what is artificial intelligence?

 
Artificial intelligence is not a new thing. If we ask somebody who works in the automobile industry, the concept of using AI to actualize auto-driving has been going on for decades. With the advent of affordable super-computing and 5G at the horizon, it should not be long before we can get hold of a real “automobile” in the foreseeable future. How about medicine?
 
Radiology
Diagnostic radiology is one area AI might be of help in the screening of abnormality. “… {T}he authority would begin studying the feasibility of applying artificial intelligence in the frontline clinicians' workflow at one of the city's A&E departments by the end of this year.” (1) The spokesman stressed that the new implementation is not meant to replace doctors, but rather to assist clinicians to refine logistics.
 
The medical literature has studied the prevalent fact that even the most experienced radiologist will miss lesions and diagnoses (2) – a phenomenon called perceptual error. Needless to say, for an emergency physician, the same will happen.
 
Perceptual error
Perceptual error, as it stands, is a concept to distinguish faults resulting from cognitive error. The latter refer to errors committed by doctor as a result of knowledge deficiency. In an example given in the paper (2) below, a man in his seventies with a history of bilateral total hip replacement presented with painful left hip. The radiologist first reported, incorrectly, “small-particle disease”. It was later found that “the proximal left femur was noted to be expansile, with cortical and trabecular thickening, and it featured a blade-of-grass advancing edge … These findings were most consistent with a diagnosis of Paget disease.” The error was attributed to the insufficient knowledge of the reporting radiologist on Paget disease, otherwise known as “knowledge gap”.
 
The second type is called perceptual error. In this type of error, there is no knowledge deficit on the doctor’s side. It is caused by the natural limitation of our brain. In order to survive this world, our brain has evolved to process information that is relevant in the context, and neglect info that is irrelevant. But for a doctor, whether the information is relevant or irrelevant will depend on how the brain interprets the clinical context. In an example quoted in the paper, the radiologist overlooked a lung lesion in a plain x-ray image of the shoulder, simply because of location – the lesion lies outside the area of interest to him. In the paper, twelve types of errors were introduced to classify errors in diagnostic radiology. For those interested in radiologic error classification system, it is worth to take a look.
 
Is artificial intelligence a way out?
Today, wherever you go, people talk about AI, and it seems AI is the future, and AI is the answer to everything. I think this is too optimistic. On the other hand, some people are very skeptical on the use of AI, and projected the views of Hollywood sci-fi movies to demonize it. Again, this is also ill-founded.
 
Today, if you google the phrase “emergency medicine artificial intelligence”, more than 28 million hits would prop up in less than 1 second. What does that mean? It means we must face the reality that AI is here to stay, and it will definitely affect the way we practice emergency medicine. And as an emergency physician, we need to learn to embrace it and live with it. For your interest, there is a review article titled “Artificial intelligence in emergency medicine” written by Nan LIU (3). It summarizes the use of AI and machine learning for numerous applications in recent years.
 
Just for fun, you can search the following phrases:
- artificial intelligence and machine learning in emergency medicine
- how artificial intelligence could transform emergency department operations
- machine learning emergency medicine
- ai in the er
- ai and emergency rooms
- ai emergency room
And see what new ideas you can get from the search engine. If you are interested in this topic, you are welcome to send me your thoughts.
 
Dr Ludwig TSOI
28 Mar 2019
 
Reference
1. As many as eight doctors missed X-ray signs in fatal lung cancer blunder. South China Morning Post (2 Feb 2019).
2. Michael A. Bruno, Eric A. Walker, Hani H. Abujudeh. Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction. Radiographics Oct 14 2015. https://pubs.rsna.org/doi/10.1148/rg.2015150023 (last assessed 28 Mar 2019)
3. Nan Liu, Zhongheng Zhang, Andrew Fu Wah Ho, Marcus Eng Hock Ong. Artificial intelligence in emergency medicine. J Emerg Crit Care Med 2018;2:82.

From the Editors    Dr Chor-man Lo & Dr Sam Siu-ming Yang

Artificial intelligence (AI) has caught much attention in recent years. Its application in Medicine is expected to produce dramatic change in the role of doctors. For the time being, the use of AI is mainly limited to assessment and interpretation of fixed objective data which will minimize inter-rater variation. Medical specialties such as diagnostic radiology and pathology are

examples which can utilize AI to achieve greater efficiency and avoid errors arising from human fatigue and perceptual bias. While its development is still at infancy, its focus is mainly on facilitating rather than replacing human decision making. Our President, Dr Ludwig Tsoi will discuss this topic in more details.

Going to the part of Council News, HKSEMS has been collaborating with the School of Chinese Medicine of Baptist University to deliver a module in Emergency Medicine. Traditional Chinese Medicine (TCM) treats patients as a whole and is well-known for holistic care while western medicine works on a well-defined anatomical, physiological and pathological basis. This allows the western medicine to measure its treatment effect quantitatively and practice evidence based medicine. Western medicine and TCM can complement each other and it is common that elements of western medicine are incorporated into the curriculum during the teaching of TCM. Nevertheless, training in TCM has relatively less exposure on the management of acute medical problems. Such Emergency Medicine module allows cross fertilization for the benefit of All.

Hope your enjoy the new issue of our newsletter. 

Council News

Dear Members,

Here comes the new issue of HKSEMS Newsletter in 2019
Let’s walk through the activities that have been conducted in the last 3 months!


Member’s Activity-Overseas Speaker Education Symposium- Thromboelastometry (TEM) Guided Therapy on Trauma Coagulopathy
 
HKSEMS has been invited by Werfen Hong Kong Limited to co-organize a symposium on Patient Blood Management on 21st February in Sheraton Hotel and Towers. Dr. James Winearls, the Lead Cardiac Intensive Care Consultant at the Gold Coast University Hospital, delivered a very inspiring talk, offering our members a new dimension in the management of hemorrhagic shock in Trauma.
More than 30 members enjoyed the following Dinner with delicious food and they enjoyed the precious chance for gathering and connecting.

粵港澳急診與災難醫學聯盟合作意向書
 
Dr.  Ludwig Tsoi represented HKSEMS to sign the 粵港澳急診與災難醫學聯盟合作意向書 on 25/2/2019. This kicked off the collaboration of Hong Kong with our counterparts in the Greater Bay Area.

Induction Course for new EM doctors
 
This induction program, our conjoint function with Hospital Authority Head Office IEC (Infection, Emergency and Contingency) was held on 4 January 2019 in Tang Shiu Kin A&E Training Centre. This is a half day program, aiming to offer new comers (including Emergency Medicine Basic Trainees, Trainees from other Specialties and Interns rotated to A&E) basic and practical knowledge for survival in the Emergency Department.
Our President, Dr. Ludwig Tsoi, promoted ACEM 2021 to the audiences after his lecture on the Principles of Emergency Medicine. 

EM module for School of Chinese Medicine in HKBU
 
HKSEMS is actively involved in different types of education programs. In addition to courses for the general public and health care professionals, we also teach the students in the School of Chinese Medicine of HKBU. This program composed of lectures in weekly basis for 2 months, plus a half day course on BLS in TSK AETC.
Our President, Dr. Ludwig Tsoi delivered the first lecture in the EM module, introducing Emergency Medicine to the students of Chinese Medicine in HKBU.
Our Vice-President, Dr. Ben Wan, who is also a very experienced ACLS instructor, delivered a lecture on the management of Cardiovascular Emergencies - the Western Medicine Perspective.

 
Medical Consultancy service to SKH Holy Carpenter Secondary School (HCS)

HKSEMS has been invited by HCS to be their medical consultancy for the management of medical contingencies in school. Dr. CS Leung represented HKSEMS to attend the workshop with role play in the afternoon of 15/3/2019. This workshop aimed at offering the teaching staff an opportunity to familiarize with the management of health related conditions in students. Feedback was encouraging. Mr. Wong, the Vice- Principal, presented a token of thanks to Dr. Leung. 


Welcome new members ( and renewal to life members )
 
We welcome the following brothers and sisters to join our family!!
Dr. Chiang Shan Ching Edward PYNEH
Dr. Yeung Chi Yeung QEH
Dr. Wong Yan Yan Evelyn CMC
Dr. Lo Wai Ling
Dr. Wong Chun Yin

Medical Tips


ECG Rhythm Interpretation
 
The ECG rhythm is best analyzed by looking at a rhythm strip. On a 12 lead ECG this is usually a 10 second recording from Lead II.
  
1. Rate
Calculate the rate of the rhythm based on R-R interval of QRS complexes. Decide if the patient's heart rate is bradycardic (less than 60 beats per minute); within a normal range (60-100 bpm); tachycardic (100-150 bpm) or a potentially dangerous rhythm above 150 bpm such as supraventricular tachycardia or ventricular tachycardia
  
2. Pattern of QRS complexes
Check for regularity of the rhythm by measuring a series of consecutive R-R interval.
If it is irregular, determine if it is regularly irregular(e.g. sinus arrhythmia, second degree heart block) or irregularly irregular( e.g. atrial fibrillation).
 
3. QRS morphology
The normal QRS segment has a normal time duration ≤ 0.12 seconds. A narrow complex QRS segment indicates that the impulse arise from supraventricular origin (i.e. sinus, atrial or junctional). A wide complex QRS segment indicates that the impulses arise from ventricular origin or supraventricular origin with aberrant conduction.
 
4. P waves
Assess if the P wave is present. If it is absent it can be rhythm such as sinus arrest, atrial fibrillation. If it is present, look at the morphology and PR interval which may suggest sinus, atrial,  or junctional retrograde from the ventricles.
 
5. Relationship between P waves and QRS complexes
-AV association is the normal condition is which each P wave is followed by an QRS complex.
-AV dissociation is a condition when the relationship between P wave and QRS complex is lost. It is present in third degree heart block and ventricular tachycardia.

Upcoming Events and Conferences


The 7th Shenzhen Hong Kong EM Conference

The 7th Shenzhen Hong Kong EM Conference will be held on 25-26/5/2019 in Shenzhen. More than 40 experts from the Greater Bay Area and beyond will gather together in this important meeting. Don’t miss the chance to meet and connect with our experts. Please approach us for any further enquiries.

 
Course with HKENA
 
Please enroll if you are interested.


Asian Conference on Emergency Medicine (ACEM) 2021

The 11th ACEM organized by HKSEMS will be held on 17th to 19th December 2021. Please save the date, and see you on this big day!!
 
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